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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F a;•OFFICE USE; ::.y... 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES l YEAR FROM DATE 'ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. ' <br /> JOB ADDRESS/LOCATION 5-e /lri [L CENSUS TRACT <br /> Owner's Name /y GS YV G G Phone7 Z <br /> f} 71f <br /> Address. �a a av �/}S /C . <br /> city <br />. Contractor's Name d✓ ,. ._e.°° <br /> License Phone <br /> .+�'-. -r � a e.+.• wn-..-.... Y'._.r-fin-.,.:�...m srz. '--... r .-..,'-....ay.__.. -� -�_ <br /> TYPE .OF WORK (Check): NEW WELL '/ DEEPEN ', RECONDITION /—f DESTRUCTION' <br /> PUMP INSTALLATIONf / PUMP REPAIR/7 Pump REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTYiLINE - PRIVATE DOMESTIC WELL.. PUBLIC DOMESTIC WELL d <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ,� <br /> ' Industrial Cable Tool Dia. of Well Excavation (A <br /> Domestic/private __f_.._ Drilled Dia. of Well Casing _.-• <br /> Domestic/public Driven Gauge of Casing • <br /> tIrrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection 7 1 Rotary_____j Type of Grout <br /> Disposal E Other Other Information <br /> Geophysical , -- ,A Surface Seal Installed-By: <br /> PUMP INSTALLATION: Contractor <br /> t <br /> Type oflPump H.P. f <br /> t � � <br /> PUMP REPLACEMENT , / / State Work Done <br /> PUMP '.REPAIR: <br /> /? .State Work Done. , <br /> DESTRUCTIONOF. WELL: Well Diameter Lf - <br /> . approximate Dept�>,� , <br /> Describe Materiaf and Procedure it <br /> I-hereby agree to -comply with al3l laws and regulations of the San Joaquin Local Health District <br /> and. the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after 'completion of my work on a new well, I will. furnish the .San Joaquiti� cal Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the..wel1'in use... The above <br /> information is .true to- the best ,of my..knowledge and belief. TWILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO OUTING AN A INSPECTION. <br /> SIGNED TITLE n <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPAUMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY 4. <br /> DATE , � I <br /> ADDITIONAL COl mns" : , 1 <br /> PHASE I GROUT INSPE ION P =MNAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY —Z; k DATE --7> <br /> E4 1426 Rev. 1-74 ,. r" h/75 -2M 4 <br />